Delayed onset paraparesis complicating epidural steroid injection with underlying spinal dural arteriovenous fistula

Written by Sharma K, Sharma VD

We report a case of a 48-year-old man with chronic back pain attributed to discogenic lumbar radiculopathy who underwent a fluoroscopy-guided L2–3 interlaminar epidural steroid injection. 4 h later, he developed acute paraparesis, sensory loss below T10 level and urinary retention. MRI of the thoracic spine revealed diffuse abnormal T2/FLAIR signal and extensive vascular flow voids. A spinal dural arteriovenous fistula was confirmed on spinal angiography. Embolization of the spinal dural arteriovenous fistula resulted in significant improvement of symptoms. We review previously reported cases and current understanding of the pathophysiology of this complication. All cases had symptom onset several hours after the procedure. There seems to be a trend toward better outcomes with earlier treatment.
Spinal vascular malformations are a group of rare disorders of the spinal cord vasculature. An examination of the National Inpatient Sample database, which constitutes approximately 20% of hospital admissions in the USA, revealed an average of 300 new cases per year [1]. Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal vascular malformation [2]. Clinical features of SDAVFs include gait difficulties, paresthesias and sensory loss in lower extremities, sphincter disturbances and progressive paraparesis [2,3]. The diagnosis of SDAVF is usually delayed and patients are often initially misdiagnosed with other spinal conditions [3]. Up to 37% of patients with SDAVF may initially be misdiagnosed with degenerative disc disease, some of whom may receive symptomatic treatment with epidural steroid injection (ESI). This case demonstrates a rare but serious complication of ESI in the setting of undiagnosed SDAVF.

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